Psychiatry and the Pressure to Prescribe

Hugh Middleton, MD, posted  an interesting article on Mad in America, October 1, 2015.  It’s called Hey; Don’t Just Shoot the Messenger!    Dr. Middleton is a British psychiatrist who  is a founding member of the Critical Psychiatry Network, and was a co-author of the cardinal paper, Psychiatry beyond the current paradigm. (2012).

Dr. Middleton had attended a conference in London on September 18.  The conference had been organized by the Council for Evidence-based Psychiatry in order to address the topic:  “the iatrogenic harm caused by the over-prescription of psychiatric medications.”

Dr. Middleton’s paper is essentially his thoughts and reflections on this conference, and he raises some very fundamental points and questions which, in my view, warrant further discussion.  It is not particularly my intention to criticize Dr. Middleton’s paper, but rather to expand on some of the points he has made, and to supply some answers to the questions he has asked.  Here are some quotes from the article, interspersed with my comments and observations.

“Working as a psychiatrist exposes me to people who want medication as much as it does to those who don’t. We can question why and how those who want medication have come to that position, but it is commonly difficult to shift and the result is frequently a prescription with the advice ‘OK. If you want to find out whether meds can help, try this and see how you get on.’  Hardly expert knowledge or advice, but when it happens, most usually it is a response to a situation that would otherwise result in a request for another opinion and another doctor providing the prescription instead.”

I think it is indeed true that many people go to psychiatrists specifically to get drugs.  This is because it is widely known that psychiatrists will prescribe psychiatric drugs readily.  In fact, since about 1980 or so, they really don’t do much of anything else.

Dr. Middleton’s contention that this drug-seeking position is difficult to shift is probably true, but is not the primary issue, because in reality, most psychiatrists don’t try to challenge or shift that position.  For most psychiatrists, a “patient” returning at regular intervals for “med-checks” and refills is the ideal scenario. Within the psychiatric community, there is, I think, a great deal more concern expressed about non-compliant “patients” than there is about those who adhere faithfully to the prescription, and keep coming back for more.

In addition, defending the practice of over-prescribing on the grounds that refusal will simply drive the client to seek his drugs elsewhere strikes me as indefensible.  Essentially it amounts to:  “I must do something that’s ethically and professionally questionable, because if I don’t, somebody else will.”

. . . . . . . . . . . . . . . . . 

“Many of the distressing stories we heard at Roehampton were of people who had tried one antidepressant after another in the hope of relief … where was the belief that somehow, somewhere there is a pill that can safely and reliably relieve their distress coming from?”

Actually, it is psychiatry’s standard message, and has been for about the past 30 years:  we’ll try different medications, or combinations of medications, until we find the one that’s right for you:  the one that corrects the chemical imbalance in your brain.

In this regard, here are two quotes:  the first from the APA, and the second from the Mayo Clinic:

“Medication: Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain. These medications are not sedatives, ‘uppers’ or tranquilizers. They are not habit-forming. Generally antidepressant medications have no stimulating effect on people not experiencing depression.

Antidepressants may produce some improvement within the first week or two of use. Full benefits may not be seen for two to three months. If a patient feels little or no improvement after several weeks, his or her psychiatrist can alter the dose of the medication or add or substitute another antidepressant.”  APA What is Depression 2015

“Medication strategies

If you’ve already tried an antidepressant and it didn’t work, don’t lose hope. You and your doctor simply may not have found the right dose, medication or combination of medications that works for you. Here are some medication options that your doctor may discuss with you:

Give your current medications more time. Antidepressants and other medications for depression typically take four to eight weeks to become fully effective and for side effects to ease up. For some people, it takes even longer.

Increase your dose. Because people respond to medications differently, you may benefit from a higher dose of medication than is usually prescribed. Ask your doctor whether this is an option for you — don’t change your dose on your own.

Switch antidepressants. For a number of people, the first antidepressant tried isn’t effective. You may need to try several before you find one that works for you.

Add another type of antidepressant. Your doctor may prescribe two different classes of antidepressants at the same time. That way they’ll affect a wider range of brain chemicals linked to mood. These chemicals are neurotransmitters that include dopamine, serotonin and norepinephrine.

Add a medication generally used for another condition. Your doctor may prescribe a medication that’s generally used for another mental or physical health disorder, along with an antidepressant. This approach, known as augmentation, may include antipsychotics, mood stabilizers (lithium or anti-seizure medications), anti-anxiety medications, thyroid hormone, beta blockers, stimulants or other drugs.” Mayo Clinic: Depression (major depressive disorder): Treatment-resistant depression 2015

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Back to Dr. Middleton’s paper: 

“What was the person who went to the doctor because they were distressed by difficult circumstances actually looking for? They were having difficulty sleeping. The doctor might have prescribed a benzodiazepine sleeping pill, but we are all quite rightly very wary of benzodiazepines, and an SSRI is the more commonly used alternative. This is not because there is confidence it will work, but because that is all the doctor can do under such circumstances, and a prescription is frequently received as a symbolic token of concern and acknowledgment of the recipient’s difficulties.”

Actually, that is very emphatically not all that a physician can do under these circumstances.  A physician in these circumstances can (and, I suggest, should) conduct an examination to determine if the sleeplessness might be the result of an actual illness.  If, in the unlikely event that a genuine pathology is identified, the physician should either treat that pathology, or refer the patient to someone who can. But if no pathology is found, which would almost always be the case, the physician should inform the client that his sleeplessness is not a medical matter, and is therefore outside the scope of a physician’s practice.  The physician might also provide the person with a list of potentially helpful community resources.  Such a list might contain psychiatric survivor groups, life coaches, gymnasiums, nutritionists, counselors, etc…

Dr. Middleton’s contention that “…a prescription is frequently received as a symbolic token of concern and acknowledgment of the recipient’s difficulties” is probably true in some cases, but it is also somewhat condescending and patronizing, and does not constitute a justification for the prescribing of drugs that Dr. Middleton himself concedes are  “…of such dubious value…”, and that entail  “…so obvious a set of adverse effects…”

. . . . . . . . . . . . . . . . 

“I am sure practitioners reading this will recognise the cycle and the deeper and deeper holes they and their clientele can get into as it goes round and round, but what starts it? Why did that person go to the doctor when they were distressed by difficult circumstances?”

Here again, I think the answer to Dr. Middleton’s questions are clear.  Why do people consult psychiatrists when they are distressed by difficult circumstances?  Because for the past forty years, psychiatry, ably abetted by the pharmaceutical industry, has used every opportunity and every means at their disposal, to promote the hoax that distress (regardless of its source) constitutes an illness!  Since DSM-III (1980), any “…clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with…a painful symptom (distress)…” (DSM-III, p 6) is an illness, and psychiatry has incorporated this medical travesty into its daily business without any indication of compunction or misgiving.

Dr. Middleton goes on to ask:

“How can our institutions mark and respond to the fact that someone might have become overwhelmed and incapacitated by life’s challenges without having to identify them as ‘ill’?”

And here again, the answer is clear.  Our social, political, and community institutions cannot respond effectively and appropriately to individuals experiencing distress until the medical hoax has been exposed and ousted.  And the greatest obstacle to this exposure and ousting is psychiatry itself, whose response to the recent waves of criticism has been ever deeper entrenchment and ever more vehement insistence that their concepts are valid, and that their “treatments” are safe and efficacious.

No substantive progress is possible in the direction advocated by Dr. Middleton until psychiatry’s hoax is universally discredited and abandoned.

. . . . . . . . . . . . . . . . 

At this point Dr. Middleton moves, with enormous professional courage, to an even more fundamental issue:

“Put very bluntly, a lot of psychiatric prescriptions are issued (not only to detained patients) because a negotiation has been conducted between the prescriber, the patient and the patient’s associates resulting in ‘agreement’ that the patient should take something to quieten them down.”

Note that Dr. Middleton has not written that the individuals should take something to “treat their illnesses” or to “medicate their psychoses”.  The phrase he used is:  “to quieten them down”.  And in this regard, I think he is being entirely accurate and candid.

But his accuracy and candor inevitably compel us to ask, and indeed Dr. Middleton himself asks, a very important question:  why do we need to maintain the pretense that the individual has an illness, and that psychiatrists are the medical specialists who treat this illness, just to quieten someone down?  And we also need to address the entailed question:  why is it that the people whom psychiatry “quietens down”, are denied the rights and due process that have become an integral aspect of “quietening people down” in non-psychiatric contexts?

And here again, the answers are clear:  because psychiatry self-servingly and strenuously resists changes to the status quo in this area, and, at least here in the US, is avidly promoting legislation to expand its power, influence, and scope.

And, of course, the truly important question:  is this person, whom psychiatry deems to be in need of quietening down, actually expressing a genuine and important grievance in the only way that he or she knows how? never even gets asked.  Psychiatry, with its routine dismissal of people’s concerns as symptoms of illnesses, is the very epitome of disrespect.

The status quo is not the result of some blind or random historical processes.  Rather, it is the direct product of psychiatry’s insatiable lust for prestige and recognition, harnessed to pharma’s equally insatiable lust for profits.

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“It isn’t nice, but very often psychiatrists find themselves powerless conduits of such forces [expectations of social order], and understanding what they do and why has to include a recognition of this. We have been drugging and incarcerating inconvenient people for centuries and although this must change, wider expectations remain and they are deeply embedded in our understanding of how an ordered society should conduct itself. Of course we have to shout as loudly as we can in criticism of those who cynically exploit the opportunities this provides, but we also have to address the core issues themselves.”

If Dr. Middleton is correct, and psychiatrists very often find themselves powerless conduits of the forces of social expectation, it has to be said that they have kept any misgivings that they entertain regarding such powerlessness deeply hidden.  I don’t ever recall hearing, or even hearing about, a psychiatrist who conceptualized the committal process as anything other than a necessary and benign step in the “treatment” of an “illness”, one of whose “symptoms” is anosognosia.  At the present time, here in the US, the Tim Murphy Bill is working its way through the legislature with the full and enthusiastic support of the American Psychiatric Association.

Dr. Middleton laments the fact that psychiatry has been  “…drugging and incarcerating inconvenient people for centuries…”, and although he calls for changes in this matter, he mitigates this call with the contention that  “…wider expectations remain…”

Dr. Middleton’s statements in this regard are not entirely clear, but he seems to be saying something along the lines:  there’s a dirty job here, and somebody has to do it.  This may indeed be true, but it skirts the fact that what makes psychiatric commitment and enforced drugging and electric shocks such a dirty job, is the deception, that it is being done to treat an illness.  This is the innermost core issue that we do indeed have to address.  And if the psychiatric hoax is eliminated, the other core issues actually become amazingly simple.  How can we, as a society, help people in distress, particularly those who have become agitated, aggressive, and/or suicidal?  Take the psychiatric elephant out of the living room, and an endless array of commonsense strategies present themselves.

People, both individually and collectively, have been successfully and compassionately ameliorating one another’s distress throughout human history.  It is not quantum physics, or high tech.  It involves no great biochemical or neurological insights.  There is no need for electrical equipment, and there are no treatment guidelines or treatment plans.

But when every potential strategy or development has to be subordinated to the fell hand of psychiatric hegemony, and when every proposal has to be integrated into the psychiatric hoax, genuine progress becomes impossible.

. . . . . . . . . . . . . . . . 

“Obviously there are those who think that what they do is appropriate and justified, but I would venture that many psychiatrists actually do what they do more often because they feel themselves to be powerless servants of wider social pressures, and would dearly like to be able to do it differently.”

Here again, I can only say that if indeed many psychiatrists feel themselves to be powerless servants of wider social pressures, they are keeping very quiet about it.  And as for the contention that they would dearly like to be able to do it differently, I can only ask:  what’s stopping them?

In my experience, psychiatrists generally are deeply attached to the medical model of human distress, and to the various broken brain theories, because, spurious and disempowering as these concepts are, they provide psychiatry with the appearance of legitimacy, and enable them to make a good living pushing pills.

I can accept that some psychiatrists “in their hearts” recognize that their profession is a sham, and that their “treatments” are a mockery of genuine medical practice, but it is also a stark reality that such misgivings seldom find expression in protests or other tangible action.  Dr. Middleton and the other members of the Critical Psychiatry Network are obvious exceptions to this observation, but it is also the case that they constitute a miniscule minority within the psychiatric community.

It is commendable and courageous of Dr. Middleton to address these issues in so outspoken a manner, but, in my view, his portrayal of psychiatrists as innocent victims of forces beyond their control is neither helpful nor convincing.  Psychiatrists embraced the expansion of their “diagnostic” net to include all manifestations of human distress, willingly and enthusiastically.  And they embraced the various chemical imbalance and other broken brain theories with the same self-serving ardor.  Neither these concepts, nor the actions on which these concepts confer the appearance of legitimacy, were forced on psychiatry.  Nor, in my view, is there any way that the embracing of these concepts and practices can be construed as honest error.  This was blatant and shameless turf-grabbing and drug-pushing.

Indeed, at the present time, when confronted with the kinds of criticisms embodied in Dr. Middleton’s own paper, it is the general response of psychiatry to re-affirm its commitment to these spurious concepts, to promote its principles and practices through PR and lobbying, and to denounce and marginalize its critics.  Only five months ago, the very eminent psychiatrist Jeffrey Lieberman, MD, Chair of Columbia Psychiatry Department and former President of the APA, denounced Robert Whitaker as “a menace to society”, on the grounds that Robert had expressed some criticisms of psychiatry, even though Robert’s criticisms have always been factual, measured, and respectfully worded.  That in itself was bad enough, but even more telling and disgraceful was the fact that, as far as I can ascertain, although there were some isolated expressions of disapproval from a few psychiatrists, there was no reaction of censure or disapproval from psychiatrists generally, or from any psychiatric association, to this extraordinarily uncivil, ungracious, and unprofessional remark.

Psychiatry is not something good that needs to engage in some soul-searching and minor corrections.  Rather, psychiatry is something fundamentally flawed and rotten.  It is, and consistently demonstrates itself to be, utterly beyond the remotest possibility of reform.

  • Cledwyn Pus Poetics

    “There is a limit to how much variation an ordered society can accommodate.”

    In an ordered society, such limits are so narrow they are practically overlapping. Yes, limits, and the formulation and codification of rules regulating the conduct of each within carefully laid down parameters, so as to ensure that the liberty of one man doesn’t encroach upon that of another, are necessary, yet what society ever confined itself to said limits? Men are less determined by the principles of liberty, justice and tolerance, and the faculty of Reason whereupon the great Enlightenment thinkers rested their faith in the betterment of the species (since when we have had the most sanguinary century in history), than they are by the passions that well-up unbidden from the occult depths of our being, and whose springs no amount of knowledge, or appeals to principles, can possibly dry up.

    Every society quickly degenerates into what Berlin called a uniformitarian despotism, and Mill a tyranny of the majority.

    Fanaticism springs eternal. It is like the innermost kernel of our being, or the primum mobile. As soon as a belief enters a man’s head, it ossifies into a dogma, a certainty; scaffolds and sacrificial altars are erected in their name; heads roll, conflagrations break out, and blood flows in their wake. Upon entry into a man’s head, they begin to behave like cancerous cells, seeking to reproduce themselves in the heads of others, and like tyrants who seek to subject every contrary idea to their dictatorship.

    Fanaticism is the calling of the species. The hatred of fanaticism merely sneaks it in through the backdoor; it is itself usually nothing more than fanaticism. Depression in certain of its manifestations and abulia both stem from a defect of fanaticism. The man who is indifferent to the world and acting upon it, being a man, must be considered a fanatic manque or an aberration of Nature.

    Such people probably constitute the real aristocracy of sanity, that is, depressed people and abulics, at least when they are experiencing one of their episodes, when the knowledge of their own nullity and the nullity of everything cripples the will, yet we rarely think other men sane unless they agree with us, and nothing alien is sane to men, each and every one of whom esteems himself the oracle of the god of Reason, onto whose features men map the contours of their own madness, lending him the colors of their own insanity, for the God of reason is a god man fashions in the image of his own lunacy, which lunacy is the standard against which men measure the minds of others, and the sanity or insanity thereof, our reasoning about these resting upon postulates that are themselves symptomatic of an entrenched lunacy.

    Regarding all the questions Mr Middleton asks why it is people go to psychiatrists etc., has he really given these issues so little thought? Obviously, one reason why people are inundating the offices of psychiatrists is because life is horrendous, and people want drugs to treat the metaphorical disease of existence.

    The problem is, is that the drugs best suited to the purpose of ameliorating our woes are being kept from us, by doctors with a monopoly on their prescriptions, and due to absurd sumptuary laws regulating the consumption of pharmaceutical agents, laws based not on science (not that science should have any say in what we put in our bodies, over which the proprietor thereof is sovereign), nor upon respect for the principle of autonomy, but on puritanism, intolerance of difference, fanaticism, and the insane fear that making all drugs freely available and leaving to the discretion of the individual the decision whether or not to take a drug will plunge human society into some sort of doomsday chaos.

    (What could be more insane than man’s fanatical intolerance, and the truly dangerous delusions of entitlement and grandeur that sprout in the mind in the grip of its own fanaticism? To stare into the eyes of the man who claims he has the right to tell you what you can or can’t put in your own mouth is to stare into a bottomless abyss of madness, and to sound depths of insanity that foretell the inevitable doom of our species, for its out of such depths that springs sempiternal all the depravity and stupidity with which history is replete, whose periodic eruption in the conscious life of society Reason is powerless to control.)

    Of course, you don’t hear many doctors, or the jays imitating peacocks we call psychiatric doctors (who, like the jays in Aesop’s fable, ponce around in their purloined plumage, turning their nose up at their true kin, that is, quacks, astrologers, and other assorted charlatans and purveyors of pseudo-science and nostrums), speaking out against such laws and their monopoly on drug-dealing.

    Coming back to the point, another reason why people are inundating the offices of psychiatrists is that the profession has managed to usher in a climate of thought as profitable to its own interests as it is inimical to alternatives, many preachers and practitioners of which having entered into contemporary demonology.

    Reputation plays a huge part here. No view could be more misguided than the belief in the good sense of the average man. The faculty of judgement is easily swayed by those details that surround a belief or opinion, by the superficialities attaching thereto, such as a man’s reputation, which prepossesses in favor of its owner the judgements of others. In laying such stress upon such inconsequential details, men usually pass over in silence the essence of a man’s opinions, whereupon rests their true worth, obviously, much as they do they do when adjudging men themselves, for which and other reasons the truth is usually found to languish in obscurity, where it nevertheless always has virtue and genius for company.